Logistic Regression Analysis on the Determinants
of Stunting among Children Aged 6-24 Months
in Purworejo Regency, Central Java
Atika Rakhmahayu1), Yulia Lanti Retno Dewi2), Bhisma Murti1) 1)Masters Program in Public Health, Universitas Sebelas Maret
2)Faculty of Medicine, Universitas Sebelas Maret ABSTRACT
Background: Stunting is a representation of the state of chronic malnutrition in the first 1000 days of life that occurred in the world at an incidence of 22.2% in 2017. Stunting in children has impact on morbidity and mortality, resulting in a long-term decline socio-economic productivity of the community. The purpose of this study was to analyze the determinants of stunting in children aged 6-24 months in Purworejo, Central Java.
Subjects and Method: This was an analytic observational study with a case control design. It was conducted in 25 integrated community health posts (posyandu) in Purworejo, from October to December 2018. A sample 200 children under five was selected using by simple random sampling. The dependent variable was stunting. The independent variables were maternal mid-upper arm circumference (MUAC) at pregnancy, maternal education, paternal education, family income, family food allocation, infant birth weight, exclusive breastfeeding, complementary feeding (CF), posyandu strata, stunting monitoring at posyandu, and posyandu stunting intervention. The data was collected by questionnaire and analyzed by a multiple logistic regression.
Results: Maternal MUAC at pregnancy ≥23.5 cm (b= -1.56; 95% CI= 0.06 to 0.67; p = 0.009), high maternal education (b= 1.70; CI95% = 0.06 to 0.57; p = 0.003), high paternal education (b= -1.90; 95% CI= 0.05 to 0.51; p= 0.002), high family income (b= -1.85; 95% CI= 0.05 to 0.50; p = 0.002), family food allocation (b= -2.26; 95% CI= 0.03 to 0.37; p<0.001), birth weight ≥2,500 g (b= -1.39; 95% CI= 0.08 to 0.83; p= 0.024), exclusive breastfeeding (b = -2.04; 95% CI= 0.04 to 0.48; p= 0.002), and adequate complementary feeding (b= -1.61; 95% CI= 0.06 to 0.65; p= 0.007) reduced the risk of stunting in children aged 6-24 months.
Conclusions: Maternal MUAC at pregnancy ≥23.5 cm, high maternal education, high paternal education, high family income, family food allocation, birth weight ≥2,500 g, exclusive breastfeeding, and adequate complementary feeding reduce the risk of stunting in children aged 6-24 months.
Keywords: stunting, determinants, children aged 6-24 months Correspondence:
Atika Rakhmahayu. Masters Program in Public Health, Universitas Sebelas Maret. Jl. Ir. Sutami No. 36 A, Surakarta, Indonesia. Email: tikarakhmahayu@gmail.com. Mobile: 083124386960.
BACKGROUND
Child growth is one of the benchmarks in efforts to monitor nutritional status in a population that provides an overview of the state of nutrition and food security in a country (Atsu et al, 2017). One of the factors that play a major role in child growth is nutrition in the first 1000 days of life where the growth of children has the
most rapid increase and nutrition at this time will affect development in the future. One of the problems that arise due to chronic malnutrition in the first 1000 days of life is stunting. Stunting is a represen-tation of the state of chronic malnutrition in particular protein energy malnutrition (Hossaine et al, 2017).
Stunting is the most common form of malnutrition in children in the world with a prevalence of 22.2% or 150.8 million children in 2017 (UNICEF, 2018). 90% of the highest prevalence of stunting is in countries in Sub-Saharan Africa and Asia (UNICEF, 2013; WHO, 2014). Indonesia ranks fifth as the highest stunting preva-lence in the world with a percentage of 37.2% in 2010. The highest percentage of stunting cases in Indonesia is East Nusa Tenggara Province (51.7%), West Sulawesi (48.0%), and Nusa Tenggara West (45.3%). The high percentage of stunting was also obtained by Central Java Province with 33.9% consisting of 18.1% short and 6.7% very short (RI Ministry of Health, 2015). Purworejo is an area in Central Java with a prevalence of stunting 4,764 cases or 10.57% in 2017. The figure is indeed not the highest in Central Java but the percentage of stunting in Purworejo has always increased in the last three years, namely 9.56% in 2015 and 10.21% in 2016 (Health Office Purworejo, 2017).
Stunting has a long-term impact on individuals to society. Children with stun-ting have a greater risk of infection. The most common infection in children with stunting is respiratory and digestive infec-tions. Stunting also results in a decrease in cognitive and behavioral abilities in child-ren (Pchild-rendergast and Humphrey, 2014). Low cognitive ability due to stunted growth causes a sustained impact on socio-econo-mic conditions, such as low levels of educa-tion, productivity, and income. Stunting children also have a 2.54 times greater risk of being overweight compared to children of normal height (Utami and Sisca, 2015). The long-term impact of stunting in women is the increased risk of giving birth to infants with low birth weight (LBW) specifically due to IUGR (Intra Uterine Growth Retardation). The high morbidity
to maternal mortality also affects the increase in perinatal morbidity and mortality (Dhungana et al., 2017).
Stunting in children is multifactorial (Nkurunziza, 2017). One of the predictors of stunting is maternal factors. Pregnant women with MUAC <23.5 cm indicate a protein energy deficiency at risk of giving birth to LBW infants who if not treated properly have a greater potential for stunting. Mothers with low education risk 5.1 times more likely to have stunting children (Rahayu and Khairiyati, 2014). The level of maternal knowledge is known to have a significant relationship with the incidence of stunting (Rosha et al., 2012).
Child factors also become one of the main predictors of stunting. Children with a history of LBW have a risk of 5.87 times greater stunting (Rahayu et al., 2015). Male infants and infants who have a history of neonatal disease have a greater risk of stunting (Aryastami et al., 2017). Exclusive breastfeeding also has a significant effect on stunting. Children with exclusive breast-feeding have a higher body length/age or height/age Z-score higher than children with non-exclusive breastfeeding (Kuchen-becker et al., 2015). Complementary feed-ing has a significant relationship to the inci-dence of stunting, especially the history of starting complementary feeding. Children with early complementary feeding are at risk 2.8 times more likely to experience stunting. Proper administration of comple-mentary feeding has an impact on low energy and nutrient intake which has an effect on increasing the incidence of stunting (Khasanah et al., 2016).
Family economic status has an influ-ence on the incidinflu-ence of stunting in child-ren. The risk of stunting is 4.13 times greater in children from families with low economic status. Policies to reduce the pre-valence of stunting in Indonesia must also
consider the cleanliness of water, latrines and sanitation through a multisectoral app-roach. Government programs that support the target of reducing stunting prevalence are also needed to accelerate the achieve-ment of these targets (Torlesse et al., 2016).
SUBJECTS AND METHOD 1. Study Design
This was an analytic observational study with a case control design. The study was conducted in 25 integrated health posts in Purworejo, Central Java, from October to December 2018.
2. Population and Samples
The target population of this study was children aged 6-24 months. A sample of 200 children aged 6-24 months was selected by simple random sampling.
3. Study Variables
The dependent variable was stunting. The independent variables were maternal MUAC at pregnancy, maternal education, paternal occupation, family income, family food allocation, infant birth weight, exclu-sive breastfeeding, and complementary.
4. Operational Definition of Variables
Stunting was defined as children nutritio-nal status assessed based on the Z-score calculation which refers to the body length anthropometric data according to the age of children aged 0-24 months. The measuring instrument used is the length board or infantometer. The measurement scale was continous and transformed into dichoto-mous coded 0 for normal (z-score ≥-2 SD) and 1 for stunting (z-score <-2 SD).
Maternal MUAC at pregnancy was defined as size of maternal MUAC taken during the first examination of pregnancy. The data were measured by MUAC tape. The measurement scale was continous and transformed into dichotomous coded 0 for <23.5 cm and 1 for ≥23.5 cm.
Maternal education and paternal education were the last level of education attained by mother and father. The data were collected by questionnaire. The mea-surement scale was categorical, coded 0 for low <senior high school and 1 for ≥senior high school.
Family income was defined as the average of family income as an economic source received within the last six months. The data were collected by questionnaire. The measurement scale was continous and transformed into dichotomous coded 0 for <minimum regional wage and 1 for ≥mini-mum regional wage).
Family food allocation was defined as percentage of family expenditure used for food needs compared to total expenditure. The data were collected by questionnaire. The measurement scale was continous and transformed into dichotomous coded 0 for low (<60%) and 1 for high (≥60%).
Birth weight was defined as infants body weight measured within 24 hours after birth. The data were collected by maternal and child health book record. The measurement scale was continous and transformed into dichotomous coded 0 for <2,500 g and 1 for ≥2,500 g.
Exclusive breastfeeding was defined as the infant only received breast milk, no other liquids or solids are given (not even water) with the exception of oral rehy-dration solution, drops/syrups of vitamins, minerals or medicines from birth to six years old. The data were measured by ques-tionnaire. The measurement scale was cate-gorical coded 0 for non-exclusive breast-feeding and 1 for exclusive breastbreast-feeding.
Complementary feeding was defined as the provision of food provided in addi-tion to breast milk until a 2 year old child. The data were collected by questionnaire. The measurement scale was continous and transformed into dichotomous coded 0 for
inadequate (score <mean) and 1 for adequate (≥mean).
5. Data Analysis
Sample characteristics were described by univariate analysis. Bivariate analysis used Chi square. Multivariate analysis used a multiple logistic regression.
6. Research Ethics
The research ethical clearance was obtained from the Research Ethics Committee at Faculty of Medicine, Universitas Sebelas Maret, Surakarta, Central Java, Indonesia, with number 359/UN.27.6/KEPK/2018. Research ethics included issues such as informed consent, anonymity, confiden-tiality, and ethical clearance.
RESULTS 1. Sample characteristics
Table 1 showed sample characteristics. Table 1 showed that mostly the children were male (56.5%). Most of the mother was working at home (87.0%). As many as 32.5% fathers were self-employed. As many as 72 children (36.0%) living in urban area.
2. Univariate Analysis
Table 2 showed that maternal MUAC at pregnancy ≥23.5 cm were 102 (51.0%). Mothers with high education level were 106 (53.0%). Fathers with low education level were 105 (52.5%). As many as 110 children (52.5%) were born from family with low income. As many as 102 families (51.0%) had low family food allocation. As many as 101 children (50.5%) had normal birth weigt. As many as 101 children (50.5%) received exclusive breastfeeding and 102 chidlren (51.0%) received adequate comple-mentary feeding.
3. Bivariate analysis
Table 3 showed the results of bivariate analysis. Table 3 showed that Maternal MUAC ≥23.5 cm (OR= 0.18; 95% CI= 0.09 to 0.36; p<0.001), maternal education ≥senior high school (OR= 0.16; 95% CI=
0.08 to 0.32; p<0.001), paternal education ≥senior high school (OR= 0.12; 95% CI= 0.06 to 0.27; p<0.001), high family income (OR= 0.25; 95% CI= 0.13 to 0.51; p<0.001), normal birth weight (OR= 0.14; 95% CI= 0.07 to 0.30; p<0.001), exclusive breast-feeding (OR= 0.15; 95% CI= 0.07 to 0.31; p<0.001), and appropriate complementary feeding (OR= 0.16; 95% CI= 0.08 to 0.32; p<0.001) reduced the risk of stunting in children aged 6-24 months.
Table 1. Sample characteristics
Characteristics n % Children Age 6-12 month 13-18 month 19-24 month 76 62 62 38.0 31.0 31.0 Gender Female Male 113 86 43.0 56.5 Maternal Occupation Housewife Private Employee Entrepreneur Employee/labor Etc 174 10 11 3 2 87.0 5.0 5.5 1.5 1.0 Paternal Occupation Private Employee Civil Servant Entrepreneur Employee/Labor Farmer 46 10 65 55 24 23.0 5.0 32.5 27.5 12.0 Residence Highlands Urban The coast 64 72 63 32.0 36.0 31.5 4. Multivariate Analysis
Table 4 showed the results of multiple logistic regression analysis. Table 4 showed that there was a significant effect of birth weight, exclusive breastfeeding, comple-mentary feeding, maternal MUAC at preg-nancy, maternal education, paternal occu-pation, family income, and family food allocation on the incidence of stunting in children aged 6-24 months.
Table 2. The results of univariate analysis
Variables n %
Stunting Status Yes
No 143 57 28.5 71.5
Maternal MUAC <23.5 cm
≥23.5 cm 102 98 49.0 51.0
Maternal Education Low
High 106 94 47.0 53.0
Paternal Education Low
High 105 95 52.5 47.5
Family Income Low
High 110 90 55.0 45.0
Family Food Allocation Low
High 102 98 49.0 51.0
Birth Weight Low
Normal 101 99 49.5 50.5
Exclusive Breastfeeding No
Yes 101 99 50.5 49.5
Complementary Feeding Inadequate
Adequate 102 98 49.0 51.0
Table 3. The results of bivariate analysis
Independent Variables Not Stunting Stunting OR CI 95% p n % n % Lower
Limit Upper Limit Maternal MUAC
<23.5 cm
≥23.5 cm 54 89 87.3 55.1 44 13 16.5 12.7 0.18 0.09 0.36 <0.001 Maternal Education
<Senior high school
≥ Senior high school 50 93 53.2 87.7 44 13 46.8 12.3 0.16 0.08 0.32 <0.001 Paternal Education
<Senior high school
≥ Senior high school 86 57 54.3 90.5 48 9 45.7 9.5 0.12 0.06 0.27 <0.001 Family Income Low High 66 77 60.0 85.6 44 13 40.0 14.4 0.25 0.13 0.51 <0.001 Family Food Allocation Low High 52 91 92.9 51.0 50 7 49.0 7.1 0.08 0.34 0.19 <0.001 Birth Weight <2,500 g ≥2,500 g 90 53 53.5 89.1 46 11 46.5 10.9 0.14 0.07 0.30 <0.001 Exclusive Breastfeeding No Yes 55 88 88.9 54.5 46 11 45.5 11.1 0.15 0.07 0.31 <0.001 Complementary Feeding Inadequate Adequate 90 53 88.2 54.1 45 12 45.9 11.8 0.16 0.08 0.32 <0.001
The risk of stunting was decreased by maternal MUAC at pregnancy ≥23.5 cm (b= -1.56; 95% CI= 0.06 to 0.67; p= 0.009), maternal education ≥senior high school (b= -1.70; 95% CI= 0.06 to 0.57; p= 0.003), paternal education ≥senior high school (b= -1.90; 95% CI= 0.05 to 0.51; p= 0.002), high family income (b= -1.85; 95% CI= 0.05
to 0.50; p= 0.002), high family food alloca-tion (b=-2.26; 95% CI= 0.03 to 0.37; p <0.001), normal birth weight (b= -1.39; 95% CI= 0.08 to 0.83; p= 0.024), exclusive breastfeeding (b= -2.04; 95% CI= 0.04 to 0.48; p= 0.002), and adequate complemen-tary feeding (b= -1.61; 95% CI= 0.06 to 0.65; p= 0.007).
Table 4. Multiple logistic regression analysis
Stunting OR Lower Limit 95% CI Upper Limit p
Maternal MUAC -1.56 0.06 0.67 0.009
Maternal education -1.70 0.06 0.57 0.003
Paternal education -1.90 0.05 0.51 0.002
Family income -1.85 0.05 0.50 0.002
Family food allocation -2.26 0.03 0.37 <0.001
Birth weight (≥2,500 g) -1.39 0.08 0.83 0.024 Exclusive breastfeeding -2.04 0.04 0.48 0.002 Complementary feeding -1.61 0.06 0.65 0.007 N observed = 200 -2 Log likelihood = 90.55 Nagelkerke R square = 0.75 DISCUSSION
1. The effect of maternal MUAC on the incidence of stunting
The results of this study showed that there was an effect of maternal MUAC at pregnancy on the incidence of stunting among children aged 6-24 months. This study showed that children aged 6-24 months old who had mothers with MUAC <23.5 cm were more likely to experience stunting. This result was in line with a study by Sukmawati et al. (2018) which showed that there was a significant effect of maternal MUAC in early pregnancy on the incidence of stunting among children aged 6-24 months old.
Maternal MUAC at the beginning of pregnancy of <23.5 cm represented chronic energy deficiency (CED). It occurred due to an imbalance between the energy obtained with the energy released in the period of time. CED that occurs in pregnant women have an impact on inter-generation mal-nutrition in children so that fetal growth
was not optimal (Sumarmi, 2016). The low supply of nutrients from the mother caused impaired placental function indicated by the small weight and size of the placenta. CED in pregnant women caused a decrease in blood flow to the placenta due to in-sufficient cardiac output. The reduced expansion of blood volume resulted in a decrease in the distribution of nutrients to the fetus so that fetal growth became hampered and affected the low birth weight of the baby (Rahayu and Khairiyati, 2014).
2. The effect of maternal education on the incidence of stunting
The result of analysis showed that there was an effect of maternal education on the incidence of stunting among children aged 6-24 months old. This study showed that children aged 6-24 months old who have mothers with low education were more likely to experience stunting. This result was supported by a study by Abuya et al. (2012) which stated that maternal
edu-cation was one of the main predictors of stunting incident in children.
Low maternal education lead to the lack of access to information and know-ledge so that awareness of nutritional needs and clean and healthy life behaviors cannot be applied maximally (Vollmer et al., 2017). Mothers with high leve of education have more mature considerations in making decisions, such as parenting, family plann-ing, and better use of health facilities. The rate of early marriage and the birth of high-risk babies from mothers who were too young can indirectly be prevented because women would spend more time in school (Aldorman and Headey, 2017).
3. The effect of paternal education on the incidence of stunting
The result of analysis showed that there was an effect of fathers’ education on the incidence of stunting among children aged 6-24 months old. This research showed that children aged 6-24 months old who have fathers with low education were more likely to experience stunting. This result was supported by a study done by Haile et al. (2016) which stated that stunting incident was low among children who have highly-educated fathers.
The father as the head of the house-hold has a big influence on the sustain-abilities of the household, one of them was parenting. Fathers with higher formal edu-cation have better knowledge and insight into nutritional needs and the application of hygiene. Father's education was also related to better access to family health facilities. Better income can also be obtained by the father with high level of education, this was related to the type of employment (Najnin et al., 2018).
4. The effect of family income on the incidence of stunting
Based on the result of analysis, there was an effect of family income on the incidence
of stunting among children aged 6-24 months old. This study showed that child-ren aged 6-24 months old who have low family income were more likely to experi-ence stunting. This result was supported by a study done by Rahayu et al. (2018) which stated that low income families were more likely to have children with stunting.
Families with low income were rela-tively only able to use limited health ser-vices. Low income affected the lack of purchasing power, which made it difficult to get adequate access to food. As a result, the quality, quantity, and variety of food consumed was low, especially foods for the growth of children such as sources of protein, vitamins and minerals (Kusuma-wati et al., 2015). Families with low econo-mic levels also tend to allocate the income for other needs beside food, therefore, family nutrition was not fulfilled (Custodio
et al., 2010).
5. The effect of family food allocation on the incidence of stunting
The result of analysis showed that there was an effect of family food allocation on the incidence of stunting among children aged 6-24 months old. This research showed that children aged 6-24 months old who have low family food allocation were more likely to experience stunting. This result was supported by a study done by Masrin et al. (2014) which stated that there was an effect of food security on the incidence of stunting.
Food allocation was the basis of food distribution in the household. The high allocation of family food can increase family food security, both in quantity and quality, which has an impact on fulfilling optimal nutritional needs. Higher income to be allocated for food needs would pro-vide adequate energy and protein, thereby reducing the risk of growth delay due to lack of access to food (Masrin et al., 2014).
6. The effect of birth weight on the incidence of stunting
The result of analysis showed that there was an effect of birth weight on the incidence of stunting among children aged 6-24 months old. This result was in line with a study done by Abera et al., (2018) which stated that children with low birth weight have higher risk to experience stunting.
Infant birth weight was related to long-term growth and development. LBW babies have a greater risk of disruption of development and growth (Ministry of Health, 2016). LBW was the most dominant risk factor associated with stunting in children. Children with a history of LBW were 5.87 times more likely to suffer from stunting. LBW infants have less anthropo-metric size so that it influenced the ability to grow and develop in the future (Rahayu et al., 2015). LBW along with inadequate nutritional intake, limited health services, and prone to infection would increase the risk of stunting due to stunted growth (Arifin et al., 2012).
7. The effect of exclusive breastfeed-ing on the incidence of stuntbreastfeed-ing
Based on the result of analysis, there was an effect of exclusive breastfeeding on the incidence of stunting among children aged 6-24 months old. This result was supported by a study done by Uwiringiyimana et al. (2018) which stated that children with a history of exclusive breastfeeding were less likely to experience stunting.
Exclusive breastfeeding provided all the important nutrients that were useful in the growth and development of children in the first 6 months of life that can prevent stunting (Uwiringiyimana et al., 2018). Breast milk contained vitamins A, D, E, K, B12, and substances that helped in the absorption of calcium and basic minerals. Breast milk also contained growth
hor-mones that increased the growth process in the infants digestive system and protect the babies against bacteria and viruses (Kismul
et al., 2018).
8. The effect of complementary feed-ing on the incidence of stuntfeed-ing
The result of analysis showed that there was an effect of complementary feeding on the incidence of stunting among children aged 6-24 months old. This research showed that children aged 6-24 months old who got inadequate complementary feeding were more likely to experience stunting. This result was supported by a study done by Uwiringiyimana et al. (2018) which stated that complementary food intake that was not optimal was one of the main factors in the incidence of stunting in children other than LBW, non-exclusive breast-feeding, and exposure to disease.
Complementary food has an import-ant role in introducing new types of food to babies, fulfilling the nutritional needs of the baby's body which can no longer be supported by breast milk, and supporting the development of the child's immuno-logical system for food and drink. The correct complementary food was given in adequate amount, time, texture, variety, method of administration, and the principle of hygiene. Impaired growth at the begin-ning of life was caused by chronic mal-nutrition since in the womb, the inproper time of giving the complementary food, complementary food which was not nutriti-onally adequate according to the baby's needs, and inaccurate pattern of comple-mentary food according to age. Children who have received complementary food prematurely were 2.8 times more likely to have stunting than children who got complementary food in the right time (Khasanah et al., 2016). Poor complemen-tary food intake resulted in an increase in the prevalence of stunting in children. This
was due to an imbalance in regulating energy intake and output in the body (Sarma et al., 2017).
This study concluded that stunting was influenced by maternal MUAC at the beginning of pregnancy, maternal educa-tion, father's occupaeduca-tion, family income, family food allocation, infant birth weight, exclusive breastfeeding, and complemen-tary feeding.Maternal MUAC in early preg-nancy of <23.5 cm, low maternal education, low father education, low family income, low family food allocation, low birth weight, non-exclusive breastfeeding, and inade-quate complementary food intake increased the incidence of stunting in children aged 6- 24 months old.
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